1329
EDITORIAL
ST elevation after myocardial infarction: what does it mean?
L A Piérard
...................................................................................................................................
Heart 2007;93:1329–1330. doi: 10.1136/hrt.2007.119131
See article on page 1376
.............................................................................
A
cute coronary syndromes are currently clas-
sified according to the presence or absence
of ST elevation at hospital admission. ST
elevation usually reflects acute thrombotic coron-
ary occlusion. The most effective treatment con-
sists in recanalisation of the occluded artery as
soon as possible, preferably by primary percuta-
neous coronary intervention (PCI) or by thrombo-
lytic treatment. However, myocardial salvage relies
on rapid, and sustained myocardial tissue perfu-
sion. Epicardial patency does not necessarily imply
adequate perfusion at the myocyte level. Alteration
of endothelial integrity, tissue oedema, platelet
aggregation, neutrophil infiltration, distal emboli-
sation of thrombus can compromise the restora-
tion of myocardial perfusion. This low-reflow or
no-reflow phenomenon related to microvascular
damage can be demonstrated by several imaging
modalities. It was first observed 15 years ago by
intracoronary contrast echocardiography.1
Myocardial contrast echocardiography, positron
emission tomography or cardiac magnetic reso-
nance can distinguish between adequate tissue
perfusion and microvascular obstruction. This
distinction is clinically important. Indeed, absence
or impairment of myocardial reperfusion leads to
more extensive necrosis and more frequent com-
plications, such as left ventricular (LV) dysfunc-
tion and enlargement, in-hospital cardiac
decompensation and mortality, rehospitalisation
for heart failure and increased risk of cardiac
death, including sudden death.
Numerous studies have tested the usefulness of
ST-segment recovery as an easily obtainable
marker of myocyte reperfusion and of clinical
outcome. Most studies have concentrated on early
occurrence of ST resolution versus persistent
elevation, by comparing 12-lead ECGs at baseline
and soon after the start of treatment. On the
whole, most investigations have demonstrated
that early resolution of ST elevation is associated
with myocardial reperfusion, myocardial salvage,
smaller infarct area, recovery of LV function and a
lower incidence of early and late cardiac complica-
tions and mortality. These studies differ in their
........................ criteria for defining ST resolution: the timing after
reperfusion treatment, the use of snapshot ECG
Correspondence to:
Professor L Piérard, versus continuous monitoring of ST deviation, the
Department of Cardiology, inclusion or not of reciprocal ST depression, the
University Hospital Sart presence versus absence of resolution or distinc-
Tilman, B-4000 Liege,
Belgium; lpierard@
tion between complete, partial and no resolution,
chu.ulg.ac.be the method used for calculating ST deviation and
........................ the cut-off values for defining resolution.
Methods of ECG analysis differ in their accuracy
of predicting the presence or absence of tissue
reperfusion and myocardial salvage. Patients with
greater ST elevation at baseline usually have a
more extensive area at risk. Early and medium-
term mortality are accurately estimated by simply
measuring, 90 minutes after thrombolysis, ST
elevation in a single ECG lead, the lead showing
maximum deviation. The prediction is lower with
the sum of ST elevation resolution.2 Absolute ST
resolution—the ST score at baseline minus the ST
score after reperfusion—better predicts final
infarct size than relative ST resolution—absolute
ST resolution divided by ST score at baseline.3
Although the single lead approach is more simple,
many studies used the sum of ST elevation or
when reciprocal ST depression is considered, the
sum of ST deviation. When the population is
divided into two groups (presence or absence of
resolution), the cut-off value is frequently >50%
versus ,50% ST recovery.4 When partial resolution
is analysed, two cut-off points are applied: >70%
for complete and ,70% to 30% for partial
resolution.2 When continuous ECG monitoring is
used, the end points may be the time to achieve ST
recovery and the stability of the resolution.5
Absence of ST resolution usually indicates failed
reperfusion treatment and has been found to be
associated with high early mortality, whereas
complete resolution predicts a small infarct area
and low mortality.6 Partial ST resolution predicts a
larger infarct area, low early mortality but
increased long-term mortality risk.7
Early assessment is most logical when throm-
bolytic treatment is used. Absence of ST resolution
may indicate either no myocardial reflow or
persistent epicardial coronary artery occlusion,
which may warrant rescue angioplasty and phar-
macological approaches.
After angiographically successful primary PCI,
the absence of ST resolution identifies patients
who are more likely to develop microvascular
damage. This information has prognostic signifi-
cance and may be even more important if
adjunctive therapeutic options are shown to be
effective.
The predischarge ECG remains a useful tool.
Several characteristics can be observed: Q-wave
regression, normalisation versus persistence of
negative T waves, persistence of ST elevation, QT
dispersion. These measures are usually analysed at
rest but may also be assessed during an exercise or
a pharmacological stress test. In this issue of the
journal, Galiuto et al describe the functional and
Abbreviations: LV, left ventricular; PCI, percutaneous
coronary intervention
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1330
structural correlates of persistent ST elevation in consecutive
patients who underwent successful primary or rescue PCI for
first ST-segment elevation acute coronary syndrome (see article
on page 1376).8 The population was divided according to the
persistence or resolution of ST elevation at hospital discharge.
The cut-off value for defining persistent ST elevation was
>0.4 mV. Myocardial contrast echocardiography was per-
formed at discharge and conventional echocardiography at
discharge and at 6 months. An association was found between
persistent ST elevation and anterior infarction, larger micro-
vascular damage, higher wall motion score index and a greater
incidence of LV aneurysm formation. However, LV volumes
were not significantly different in the two groups, with the
exception of a larger end-diastolic volume in patients with
persistent ST elevation only at hospital discharge, but not at the
6-month follow-up.
Microvascular dysfunction has been found to be the most
important predictor of LV remodelling by Bolognese et al,9 but in
their study, the earliest measurement of LV volume was already
made at day 1 and LV dilatation was defined as an increase in
volume based on repeated measurements in individual patients.
The absence of a relation between persistent ST elevation and
LV remodelling may be surprising. Manes et al found that
residual ST elevation at hospital discharge after anterior
myocardial infarction was an independent predictor of persis-
tent LV dysfunction and of progressive LV enlargement.10
However, Bodi et al showed that patients with persistent ST
elevation had a greater end-systolic volume 1 week after
myocardial infarction, but not after 6 months.11
Persistent ST elevation in the acute phase of a myocardial
infarction has been considered as a marker of continuing
ischaemia. Later, it can be observed in patients with pericarditis
or LV aneurysm. Aneurysm was indeed more frequently seen by
Galiuto et al8 in patients with persistent than in patients with
resolved ST elevation. This contrasts with other observations
showing that ST elevation relates to akinesis and dyskinesis in
anterior and septal regions but does not indicate impaired LV
function or predict the presence of an LV aneurysm.12 All the
patients of Galiuto et al with persistent ST elevation had an
anterior infarction.8 Anterior myocardial infarcts have less
frequently adequate collateral flow and more frequently a high
amount of ischaemic tissue and higher wall stress; this may
explain the higher incidence of the no-reflow phenomenon
among patients with anterior as compared with those with
inferior myocardial infarcts.13
Persistent ST elevation is most frequently accompanied by
persistent negative T waves. Persistent negative T waves—even
in the absence of coexisting ST elevation—a few months after a
first acute myocardial infarction are independently associated
with a worse outcome.14 Persistent T-wave inversions are
related to extensive necrosis or jeopardised myocardium not
submitted to coronary revascularisation. In contrast, T-wave
normalisation before discharge is associated with stunned
myocardium and improvement of LV function. Later T-wave
normalisation seems to be associated with viable, ischaemic
and revascularised myocardium.15 In reperfusion treatment, ST
elevation developing during dobutamine or exercise stress
www.heartjnl.com
Editorial
testing has a different clinical significance from persistence at
rest. It is often associated with a biphasic response during
stress, a sign of viable myocardium in jeopardy and is an
independent predictor of functional recovery.16 17
In summary, although imaging modalities such as echocar-
diography, cardiac magnetic resonance and radionuclide
techniques provide much precise, but costly, information, the
ECG should not be used only for classifying an acute coronary
syndrome. It remains an essential tool for risk stratification and
identification of patients who require more aggressive treat-
ment strategies and careful follow-up.
Conflict of interest: None declared.
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